Urinary incontinence (UI), or involuntary urine loss, is estimated to affect more than 13 million Americans and at least half of America's 1.5 million nursing home residents (Fanti, Newman, Colling et al., 1996). The significance of involuntary urine loss for older adults and their caregivers cannot be truly appreciated because UI is an underreported, underdiagnosed, and undertreated chronic health condition that impacts daily physical functioning and quality of life. While the majority of people with UI can be successfully treated, older adults with cognitive or mobility impairments may not be offered adequate treatment.
Prompted voiding (PV) is a behavioral intervention designed to promote urinary continence in adults who need caregiver assistance for toileting. Prompted voiding is among the least invasive UI treatments, poses few health risks for those using the technique and can be used when medication or surgery is contraindicated. Benefits of PV may include fewer daily episodes of UI, a decrease in the amount of incontinent voids, and an increase in the amount of continent voids.
Prompted voiding may be an ideal intervention for family members and nursing staff caring for individuals with UI in home care and long-term care settings. Beginning a PV program does not require expensive equipment. However, successful implementation of PV requires the consistent availability of a caregiver to provide the voiding prompts and toileting assistance. While other behavioral techniques require users to have high levels of cognition and motivation, PV can be used with individuals who have physical or mental impairments. This protocol provides evidence-based clinical practice guidelines for implementing a program of PV for individuals with UI.
The purpose of this researchbased protocol is to provide information for implementing a treatment program of PV for older adults with urge, stress, mixed, or functional UI. The goals of the Prompted Voiding Protocol (PVP) are to reduce the frequency and severity of UI episodes, increase self-initiated toileting, and to prevent complications associated with UI.
Urinary incontinence is the involuntary loss of urine that is sufficient to be a problem (Fanti, Newman, Colling et al., 1996). Types of UI that may be responsive to the PVP include:
* Urge incontinence. Involuntary passage of urine occurring soon after a strong sense of urgency to void (North American Nursing Diagnosis Association [NANDA], 1999).
* Stress incontinence. Loss of urine of less than 50 mL occurring with increased abdominal pressure (NANDA, 1999).
* Mixed incontinence. Urine loss having features of both stress (urine loss with increased intra-abdominal pressure) and urge (sudden undelayable need to void) incontinence (Woodtli, 1995).
* Functional incontinence. Inability of usually continent person to reach toilet in time to avoid unintentional loss of urine (NANDA, 1999) or urinary leakage associated with inability to toilet because of impairment of cognitive or physical functioning, psychological unwillingness, or environmental barrier (Kane, 1999).
COMPREHENSIVE NURSING ASSESSMENT OF URINARY INCONTINENCE
Nursing Interventions Classification
Prompted voiding is the promotion of urinary continence for the person with limited cognitive ability through the use of timely verbal reminders to toilet and positive social feedback for toileting success (McCloskey & Bulechek, 1999, p. 540).
WHO BENEFITS FROM THE PROMPTED VOIDING PROTOCOL?
The PVP is designed for older adults with cognitive impairments who have urge, stress, mixed, or functional types of UI or who are at risk for developing UI because of cognitive or mobility limitations. Individuals with transient, overflow, reflex, or total UI or urinary retention are not likely to respond to the PVP and would benefit from other nursing interventions.
The best predictors of individuals' responses to the PVP are their success at a therapeutic trial of PV (Schnelle, 1990). Many people responsive to the intervention show a clinically significant increase in appropriate toileting behavior and a decrease in incontinence levels during a 3 -day trial of PV (Ouslander et al., 1995a). However, maximal response to the treatment may not be realized until several weeks of treatment (Palmer et al., 1994). The Figure on page 10 contains an example of the PV Treatment 3-Day Assessment and Intervention Trial.
In addition to a successful trial of PV, the following assessment criteria may indicate the most appropriate candidates for the PVP:
* Baseline incontinence rate of less than four episodes in 12 hours.
* Recognizes the need to void.
* Voids at least 50% of the time into a toileting receptacle.
* Able to maintain UI level of less than one wet episode per 12 hours with the PVP.
A comprehensive nursing assessment (Table 1) that identifies the type and patterns of UI is recommended prior to the start of any continence intervention (Fanti, et al., 1996; Lekan-Rutledge, 1996; Penn, 1990; Penn, Lekan-Rutledge, Joers, Stolley, & Amhof, 1996; Resnick, 1990; Williams & Gaylord, 1990).
The noninvasive or minimally invasive assessment tests should be performed by an RN. Assistive personnel may collect data regarding the timing and amount of UI episodes. Some areas of the comprehensive UI assessment are more invasive, require special training, and may call for consultation from continence nursing specialists, advanced practice nurses, or physicians. Assessment forms included in the full PVP include:
* Urinary Incontinence Risk Factor Checklist.
* Urinary Incontinence Assessment Factors Checklist.
* Lekan-Rudedge (1995) Rapid Assessment of Urinary Elimination.
* Three-Day PV Record.
DESCRIPTION OF THE PROMPTED VOIDING INTERVENTION
Prompted voiding is a behavioral intervention used in the treatment of UI that is designed to change the way a person reacts to involuntary urine loss. Prompted voiding seeks to change the behavioral response of both the caregiver and the individual with incontinence. Rather than allowing the individuals to empty their bladder into an incontinence aid or clothing, the caregiver will intervene prior to the bladder emptying. Individuals with UI are prompted to void their bladders into appropriate receptacles (e.g., toilet, commode, urinal, bedpan) prior to involuntary urine loss.
The three behaviors that the caregiver uses each time the PVP is initiated are monitoring, prompting, and praising. Monitoring involves asking individuals, at regular intervals, if they need to use the toilet. Prompting is antecedent to toileting assistance from the caregiver. Prompting includes reminding the person to use the toilet as well as encouraging bladder control between PV sessions. Praising is the consequence to the individual's success with maintaining bladder control (M.H. Palmer, personal communication, 1998). Praising, or feedback, is the positive reinforcing of dryness and appropriate toileting. Table 2 is a summary of PV and the caregiver behavior associated with each of the steps.
Individualization of the PVP is recommended. Clinicians using the PVP are encouraged to work with the PV technique to determine the necessary steps for each person using the intervention. In addition, identification of individual voiding patterns can promote high continence levels while minimizing the caregiver time required for completion of the PVP.
After regular voiding patterns have been identified, caregivers need to be made aware of this pattern. Posting individual toileting schedules in convenient locations and using staff meetings to discuss resident response to PV has helped some facilities maintain high levels of continence for extended periods of time. Staff adherence to the PV schedule, toileting within 30 minutes of the scheduled session, and toileting immediately after self-initiated requests is essential to achieve maximal continence levels (Palmer et al., 1994).
OUTCOMES ASSOCIATED WITH PROMPTED VOIDING
The primary outcome variables of any UI treatment are the number and volume of incontinent episodes. Secondary outcome measures may include satisfaction, quality of life, bladder symptoms, post-void residual urine, and other urodynamic measures (Blaivas, 1998). Indicators of PV success may also include dryness level, staff compliance level, and number of wet episodes (Palmer, Czarapata, Wells, & Newman, 1997). Continence outcomes identified to be responsive to PV include:
STEPS OF PROMPTED VOIDING TECHNIQUE AND CAREGIVER BEHAVIORS
NURSING OUTCOMES CLASSIFICATION (NOC): URINARY CONTINENCE
* Increase in daily average number of dry checks and non-wet episodes (Burgio et al., 1994; Colling et al., 1992; Creason et al., 1989; Engel et al., 1990; Hu et al., 1989; Kaltreider et al., 1990).
* Recognition of urge to void (Hu et al., 1989; Kaltreider et al., 1990).
* Increase in average volume of continent voids (Adkins & Matthews, 1997; Blaivas, 1998; Palmer et al., 1997).
* Decrease in average volume of incontinent voids (Burgio et al., 1994; Colling et al., 1992).
* Identification of individual patterns of UI (Colling et al., 1992).
A bladder record, such as the 3Day PV Record included in the full PVP, may be used to record UI characteristics and to evaluate the effectiveness of the PVP. A perineal pad test may be used to monitor the volume of UI episodes.
Monitoring of long-term outcomes of the PVP can be accomplished using the Nursing Outcomes Classification (NOC): Urinary Continence evaluation form (Table 3) indicators (Iowa Outcomes Project, 2000). The NOC is suggested as a system for monitoring and evaluating an individual's response to PV and for providing feedback to patients, family, and staff. In addition, NOC can help identify the need for modification of nursing interventions and as a means of documenting the contribution of nursing and other health care professionals to the maintenance of urinary continence. The NOC monitoring is recommended at weekly intervals for 2 weeks, biweekly for 6 weeks, monthly for 4 months, and on a quarterly basis for as long as the PVP is used.
SOCIAL FEEDBACK FOR TOILETING BEHAVIOR
Most PV programs have incorporated social feedback into the treatment plan (Burgio et al., 1994; Campbell et al., 1991; Colling et al., 1992; Engel et al., 1990; Hawkins et al., 1992; Hu et al., 1989; Kaltreider et al., 1990; McCormick et al., 1992; Ouslander et al., 1995a; Palmer et al., 1994; Petrilli et al., 1988; Schnelle et al., 1989). Positive social feedback involves praising the individual for successful toileting behavior including staying dry between scheduled trips to the toilet, self-initiating requests to toilet, responding positively to prompts to void, and for accurate reporting of continence status. In addition to praise for toileting performance, special attention from the caregiver, such as engaging in conversation unrelated to toileting behavior, offering fluids, or assisting with personal grooming, may encourage the person with UI to continue using the PVP.
Staff management is a crucial factor for PV success (Burgio et al., 1994; Burgio et al., 1990; Burgio et al., 1988; Campbell et al., 1991; Colling et al., 1992; Engel et al., 1990; Hawkins et al., 1992; Hu et al., 1989; Remsburg, Palmer, Langford, & Mendelson, 1999; Schnelle, Newman, White, et al., 1993). Because of the physical or cognitive decline of the individuals using the PVP, consistent completion of the PVP by professional or family caregivers is essential for continence maintenance. The nearer to a 100% completion of assigned PV sessions by the caregiver, the higher the rate of urinary continence in the individual (Palmer et al., 1994).
Staff members perceive many barriers to completion of prescribed PV assignments. Lekan-Rutledge, Palmer & Belyea (1998) found that these barriers include:
* Inadequate staff communication and support.
* Insufficient monitoring to assure the program is being implemented as prescribed.
* Inadequate numbers of staff.
* Failure to select residents who will most likely benefit from PV.
* Failure to complete regular reassessments of individuals using PV to determine effectiveness.
* Inadequate initial education for all involved staff.
* Lack of ongoing education about the program.
Of these barriers, assuring enough staff to make it possible to implement the PV intervention will be the most challenging to address. This perceived barrier may be addressed by limiting the number of individuals started on the intervention at one time and through continuing education to discuss workload tradeoffs of toileting versus time to change wet clothing or incontinence products.
Staff compliance with PV schedules has been shown to maintain improved continence rates for at least 3 to 6 months after initiation of treatment. Techniques used to maintain or increase staff compliance with PV assignments include determining standard of care, selfmonitoring of completion of PV assignments, weekly reliability checks of self-monitoring by another individual, verbal feedback on group performance, verbal feedback on individual performance, and written feedback on individual performance.
Determining the Standard of Care
It is recommended that facilities or families using the PVP determine the standard of care for completion of assigned treatments. A completion rate of at least 60% to 80% of all assigned PV sessions should be achieved. As completion rates fall below this level, there is an increase in the number of UI episodes (Palmer et al., 1994).
Self-monitoring of Completion of Prompted Voiding Assignments
Self-monitoring of completion of PV assignments by caregivers represents the minimal level of staff management employed to assure PVP compliance. The staff member completing the PV assignment would record the results of the exchange on an incontinence monitoring form.
Weekly Reliability Checks of Selfmonitoring by Another Individual
To monitor the reliability of the self-monitoring reports and PV technique used by caregivers, a weekly performance check by supervisory personnel can be used. Supervisory staff would witness a defined number of patient-staff interactions to determine that the technique is being followed as prescribed and that self-monitoring forms are being completed properly.
Verbal Feedback on Group Performance /Verbal Feedback on Individual Performance
Verbal feedback on group performance yields high levels of compliance with PV early in its implementation. Employee performance feedback that combined visual representations (e.g., bar graphs) of employee performance (completed PV sessions) and resident UI rates with supervisor verbal feedback is one method that has been used effectively in research studies.
Written Feedback on Individual Performance
Formal letters of praise or reprimand signed by supervisory personnel, given biweekly, to assistive personnel increase employee compliance at higher levels than verbal feedback on individual performance levels. High rates of employee compliance may be realized when summary letters of employee performance, signed by supervisory and administrative personnel, are given to staff members and also placed into employee records every 6 months.
ASSESSING EFFECTIVENESS OF PROMPTED VOIDING
To evaluate the PVP and determine if UI has been managed effectively, both process and outcome factors should be evaluated for each user of the PVP. The process of implementing the PVP is evaluated through staff members' completion of the PVP Process Evaluation Monitor contained in the full protocol.
Patient outcomes can be evaluated using the NOC: Urinary Continence Measurement Scale. A copy of the NOC: Urinary Continence evaluation form is presented in Table 3. The NOC: Urinary Continence evaluation is an example of an outcome measure that should be completed frequently throughout the PVP as outlined on the form.
- (For additional references, please see Sidebar on page 12.)
- (R) = Research
- (L) = Literature
- (N) = National Guideline
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COMPREHENSIVE NURSING ASSESSMENT OF URINARY INCONTINENCE
STEPS OF PROMPTED VOIDING TECHNIQUE AND CAREGIVER BEHAVIORS
NURSING OUTCOMES CLASSIFICATION (NOC): URINARY CONTINENCE